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Form - STC - 1 4
AS BUILT SANITARY SYSTEM REPORT
OWNER A7 TOWNSHIP SEC. T W
ADDRESS 06-3ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
H10 41 SL-:-
/Gy
INDICATE NORTH ARROW y
BENCHMARK: Describe the vertical reference point used )i'ce' /X3 Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: 103,05-
Tank Inlet- Elevation: C717,40AU- Tank Outlet Elevation:
Number of feet from :nearest ° Road.: Front ;O Side A& Rear, 0 L?(7T feet
t = From "nearest- pr®pertX line' w; .Front,OSide,~Rear,O zoo t feet
Number of feet from: well f building: -3(,'
(Include this information of t e above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
r ~
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of t elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from ne st property line: Front, O Side, O Rear, 0 Ft.
umber of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:_
j. 0 Number of Lines:_ Area Built:
Width: Leng'th:_
Fill depth to top of pipe: (r
Number of feet from nearest property line: Front, O Side, O Rear,(P't.Z40'
Number of feet from well: ~d `ICY
Number of feet from building: f 7Z
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on a of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: acity:
Number of rings used: E ation of bottom of tank:
Elevation of inlet:
Number of feet from arest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector':
Dated: Plumber on job: u~-4-
License Number:
3/84:mj
PUMP CHAMBER,
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of t elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from ne st property line: Front, O Side, O Rear, 0 Vt.
umber of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines:_ Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, #t.
Number of feet from. well: y X0
Number of feet from building: / 7f ry
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on a of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: acity:
Number of rings used: ;;3E; ation of bottom of tank:
Elevation of inlet:
I
Number of feet from arest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of.feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on . job :
License Number. 1
3/84:mj
471 10 0 15-14
Wisconsin Depprtment of Industry, PRIVATE SEWAGE SYSTEM County:
Labo,andHymanRelations
INSPECTION REPORT St. Croix
Safety and Buildings Division
' (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION NW-1, SE4,sec. 14,T28-R18,Co. Rd. J 149180 Permit Holder's Name: ❑ City ❑ Village)] Town of: State Plan ID No.:
John Peitenpol Kinnickinnic
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
022-1040-20110
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION B HI FS ELEV.
Septic C_ / za Benchmark r
Dosing ~ .C ~•5~~,
Aeration Bldg. Sewer
Holding St / JC Inlet -7 4, 03
TANK SETBACK INFORMATION St/ Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Do ' NA Header / Man.
7-2
9553 ,
Aeration NA Dist. Pipe 1 e
Holding Bot. System 3.56
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand d,7,30
Model Number GPM
TDH Lift Friction M TDH Ft
Forcemain Length Dia. Dist. Towel
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length r No.Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS :5- 5
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING nu acturer:
SETBACK
INFORMATION TypeO Cmj CHAMBER Mode Nu r:
System: +rc- >02 OR UNIT
DISTRIBUTION SYSTEM
Header f hHe~ r~ Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake
Length ~ Dia ~ Length _ Dia. ~ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over r Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center ~ Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons~t, et o;.)
60 P~t-IX4C-d o;;4 4t
Plan revision required? ❑ Yes
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
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DILHR .7 a SANITARY PERMIT APPLICATION couNTY
In accord with ILHR 83.05, Wis. Adm. Code
Illl~ tr...~,~..,o .
eAA~Ak
STATE SANITARY PE T #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~A
8% x 11 inches in size. c eck i revis onto revious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
~T,9%, S T ,N,R E(or
IrAr 149 6z
o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 40 ~y V AZ L AN, l"
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Af4 5yb2~.
II. TYPE OF BUILDING: (Check One) F] State owned ❑ VILLAGE : NEAREST ROAD
❑ Public ~ 1 or 2 Fam. Dwelling- # of bedrooms a AR L T X NUMBE (
111. BUILDING USE: (If building type is public, check all that apply) O ho 40 -2A A0
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ~ New 2. ❑ Replacement 3.E] Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) +It/ ELEVATION
SQ SD Xj ft,_6'Feet qoe_ ? Feet
VII. TANK CAPACITY Site
in allons Total # Of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank __1~1 1 -1 1 El I F1 I El I El I F] F1
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plum is Signature: (No Stamps) M PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Cod :
r9ER L~ t . ~Y
5,99 Q,4UP_%iC htgaj 7-k
IX. C TY/DEPART ENT USE ONLY
❑ Disapproved Sam ry Permit Fee (Includes Groundwater ate Issued issuing ent Sign a (No S ps
~ rcharge Fee)
XApproved ❑ Owner Given Initial /
Adverse Determination /
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property -'ehh fl Q~eA -C n Do)
Location of property NN W 1/9 S 9 1/9, Section N , T_23 _N-R 19 W
Township V% n
Mailing address Q A5 eat, L", LM
R;ver ~ai15 w~ s~ ~aa
Address of site C}
Subdivision name
Lot number
Previous owner of property l,~ a lee ow ard~
Total size of parcel _N .11-i (L..on a Q.241 44AI Ran ' a.O. W +
Date parcel was created Laj cd,}ra .A Rrcardr~ tYlavZ ;q'10
Are all corners and lot lines identifiable? es No
Is thi property being developed for resale (spec house)? Yes 0
8.7.1.
Volume jIffiftand Page Number `fm i as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. 498900 ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the ounty Registe of Deeds, as Document No.
U D P 'A k.
Sign ure of Owner Signature of Co-Owner (If Applicable)
1/0 h. I
Date of Signature Date of Signature
~ a. oNY Y-, fem. K
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SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County 'J
a
OWNER/ BUYER 5~; ~n Q P. i J{ nQ
ROUTE/BOX NUMBE Fire Number
R d
eY
CITY/ STATE V0. (LS WZ ZIP S Y j2,2;?
STATE a'~v e r
PROPERTY LOCATION:'-~N W_1,11_k, Section 1 L-t' T,AJ.LN, RJW,
Town of K+ ;mac ~n u" St. Croix County,
Subdivision Lot number__.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed 's'ept'ic tank pumper. What you put into
the system can affect t e :unct on of the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix Count yy residents may be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
which was in operation prior to-July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new .sys'tems agree to keep their system properly
maintained.
The property owner agrees to submit to St.. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and .(2).after inspection and pumping (if nec-
essary), rtifatthe ionsformcwillkbessentsapthan 1/3 proximately130fdaysdpriordtoc~
C e
three year 'expiration. 1.4
I/WE, the undersigned have read the above requirements and agree
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as.set by the Wisconsin Depart-
went of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration. date.
SIGNED r
1
DATE g I Jb -1q
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
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L~~~ o~-'~yt~~+~ 7 -?Z_ I (71 S) ~-I ZS-D 165 5710 .
CST Signature Date Signed Telephone No. CST #
Parcel 022-1040-20-110 04/12/2007 12:11 PM
PAGE 1 OF 1
Alt. Parcel 14.28.18.222A-10 022 - TOWN OF KINNICKINNIC
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - PIETENPOL, JOHN D
JOHN D PIETENPOL
1379 CTY RD J
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 1379 CTY RD J
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 22.840 Plat: N/A-NOT AVAILABLE
SEC 14 T28N R18W PT NW SE COMM S 1/4 COR Block/Condo Bldg:
SEC 14; TH S 89 DEG E 438.41'; TH N 0
DEG E 525.79'; TH N 89 DEG W 66' TH N 0 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
DEG E 877.22'; TH NLY ON A CURVE CONCAVE 14-28N-18W
E 115.61' TO POB; TH NLY ON A CURVE
CONCAVE E 396.61'; TH N 41 DEG W
more...
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 917/389
07/23/1997 871/409
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 08/10/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.000 80,000 148,500 228,500 NO
AGRICULTURAL G4 17.840 2,200 0 2,200 NO
Totals for 2007:
General Property 22.840 82,200 148,500 230,700
Woodland 0.000 0 0
Totals for 2006:
General Property 22.840 82,200 148,500 230,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 122
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
a
REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DEPARTN~ENT AF * DIVISION
• M8CR, AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
111///M M63.090),& Chapter 145.045)
~ LK`NO.: SU~D!VISION NAM
' LOCATI ,/4 5..SE/CTIO%T 8 N/It/i E (o OW SHIP/MUNICIPALITY: B
l4 G
37W 10 lei
COU S BUYER'S NAME: MAILING ADDRESS:
2 - It L r 4o=
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS:
Residence 3 ~1Gew ❑Replace f^ S /D
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
IEIS EDO RS OU OS C o S~ Ps E1U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- I sy _43
B-
B- 'V'ffj' 01C f'mot
-77 40141, f .01
B-
B-
51/ A 2-` ( f~'
67 o, 5`C
6-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P
P-
P zc /O
P-_
R ,X 30 3 j 3
P- _ f
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): DAVE FWMM PLUMBING TESTS WERE COMPLETED ON:
Licensed Perk Tester & Plumber r p o
ADDRESS: FQ erty W hts Road CERTIFI TIO NUMBER: PHONE NUMBER (optional):
SIN W21
ROSE S. WIS ON
Phone 749.3656 CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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